A woman conceals her phone call from her spouseMany mental health professionals consider the three “A’s”—addiction, affairs, and abuse—sufficient reason to leave a partner. This blog addresses lower-level offenses related to the first two. While most couples can overcome low-level indiscretions in any area of the three “A’s,” when multiple indiscretions occur or the degree of severity is greater, it may be time to throw in the proverbial towel. As couples grapple with why one partner cheated or entered the depths of alcoholism or drug addiction, they need to evaluate the patterns of relating they have become used to, the interpersonal dynamics they engage in, the dances they dance, and the issues they may have brought into the relationship. One theme that consistently emerges is the degree to which couples are honest with each other. How much do they divulge? How important is it to tell the truth? Do you really need to tell your partner everything?

In Alcoholics Anonymous, we hear people say, “We are as sick as our secrets.” Family addiction therapists are fond of saying that there are no family secrets. By this, they mean that even when we believe that other family members don’t know a certain secret, that secret still has an impact on everyone in the family. If individual members don’t know the specifics of the secret, they are still impacted by it and sense or experience it unconsciously—and that can affect the whole family. I work with patients who learned in their twenties or later in life that they were adopted, that their parents were once married to an abusive spouse, or that they have a sibling they never knew, among other revelations.

I’ve also become aware of the extent to which sober and recovering clients keep things from their partners. Even in relatively healthy relationships, there appears to be a fair amount of small-scale concealment and deception, though the extent of the infractions often is debatable. Several clients I see—coincidentally or not, all men—have reported engaging in exercise cheating. What’s that, you ask? Exercise cheating, essentially, is exercising and not telling your partner, or not revealing how much or what type of exercise one engages in.

Even I have been guilty of cheating on my wife. A few years back, as I was setting up my new Philadelphia office, I decided to buy a painting by an artist that my wife and I liked. My wife studies art history, and I thought she would appreciate that I was acquiring a painting by a Temple University master’s graduate. And while $650 is no small chunk of change for this sort of thing, I thought it was a great investment for my new office. I thought I would surprise her with the purchase. Instead, she was angry. “You art cheated!” she cried as soon as she saw it. She was genuinely annoyed that I had not consulted with her on a purchase of this magnitude. Whether I was right or wrong in purchasing something of that cost for my office was not the issue. What is important is my partner’s perceived betrayal and need for dialogue, negotiation, and consultation.

Many hypothesize that cheating behavior is related to vestiges of evolutionary differences among men and women. While this theory would be a gross generalization in today’s society, it suggests that it was more adaptive in an evolutionary way for men to cheat than for women to cheat. Assuming evolution prioritizes any behavior designed to propagate one’s genes, men may benefit from spreading their genes in a quantity-focused way. Women, meanwhile, have long gestation and nursing periods which may temporarily move them to be more devoted and committed to their offspring. Thus, they benefit from finding a better quality mate. In other words, women are biologically, or at least evolutionarily, better at taking care of their young, especially in early developmental stages. Most people agree, and research appears to back this up, that most men think about sex more frequently than women do. While both men and women want to find a quality mate, men may be more inclined to seek quantity than women are.

According to this evolutionary perspective, neither men nor women want their mates to cheat because a mate who cheats may have more offspring, which in turn means that mate is less likely to care for the original partner’s offspring and more likely to leave and care for his or her new offspring. It is in a man’s evolutionarily best interest not to alert his partner to the fact he is cheating. Any behavior—sexual or not—that results in producing healthy offspring is powerfully reinforced to the extent that it aids in propagating an individual’s genes. So, infidelity and hiding that infidelity through the processes of natural selection and evolution can become more prevalent over time.

A fair question would be whether cheating sexually is related at all to other types of cheating. Just because a partner doesn’t tell a mate where he or she is going and what he or she is doing doesn’t mean that an affair is happening, and it doesn’t mean that a tendency toward nonmonogamous behavior is the cause of disingenuous behavior in the context of the couple. In fact, the point of this article is to lessen the impact of minor violations of the honesty contract. Putting small indiscretions of dishonesty in an evolutionary context may allow couples to see this behavior as resulting from the natural instincts of the animals we are. What is important, though, is that as humans we have the capacity to dialogue. This is precisely what can keep our natural tendencies in check. Speaking honestly to our partners about our needs and wants, while often challenging, is the hallmark of a healthy relationship.

Smoking gun example: A client once described an interaction he had with his wife after she busted him for smoking pot in the garage. She smelled the smoke even as he vehemently denied he had been smoking marijuana. When she found his metal pipe, still warm, he stuck to his story. “The lie just came out,” he explained later. “I was so used to it.” He eventually was able to talk about why he lied and why he has often felt the need to cover things up. It had nothing to do with infidelity, but was instead linked to his history of struggling to feel good about himself, to be able to ask for help with his emotions feelings and thoughts and to find purpose and meaning in his life. Beginning to discuss these issues with his wife and therapist helped him think more carefully about his tendency to lie and cover his tracks. He became better at advocating for himself and negotiating with his partner in a more healthy way.

Honesty is important in recovery from any mental health issue, whether it be depression, anxiety, or stress, but it is especially important in recovery from addiction and substance use because of the strong tendencies to hide, deny, and minimize one’s behaviors. Seeing an addiction psychologist or other specialist is an important first step in understanding one’s self. It is in this therapeutic relationship that a quick foundation can be set for the basis of an honest dialogue with one’s partner, friends, and family. Rebuilding relationships with those we love and who love us is essential to recovery from addiction. Understanding ourselves and the reasons we might cheat and lie can enable us to pause just long enough to ask ourselves whether we really want to go ahead with the behavior or if we might be able to rely on those close to us to help us through the difficult times. Honest communication with the people in our lives is the only way we can become and stay sober or make meaningful and lasting changes in our lives.

Woman looking out train window

Dialectical behavior therapy (DBT) is a comprehensive, evidence-based treatment approach used to treat individuals with a wide variety of issues, including relationship conflict, anxiety, depression, bipolar, self-injury, eating issues, and substance abuse. Developed in the 1980s by psychologist Marsha M. Linehan for the treatment of borderline personality disorder and chronic suicidality, this method has since been adapted and utilized to help clients with much less severe issues. The therapy can help clients who exhibit extreme emotional reactions, helping them develop self-acceptance while also learning coping skills to better regulate their emotions and handle distress. DBT uses both individual therapy sessions and group skills training, as well as telephone coaching between sessions.

The DBT model combines a behavioral therapy approach with eastern mindfulness practices. In one sense, the term dialectical refers to the goal of synthesizing the extreme opposites inherent in the rigid “black and white” thinking of many clients who have trouble regulating their emotions. “Dialectical” also applies to the core DBT principle of practicing acceptance strategies while implementing change strategies, in the process of reducing and modifying self-destructive behaviors.

This type of therapy is very support-oriented; it helps clients identify their strengths, build new skills, and increase their self-esteem. DBT focuses on cognitive issues by indentifying destructive thought patterns and replacing them with more neutral and accepting internal dialogues. It is designed to be a nonjudgmental collaboration, with the therapist and client working together to increase emotional awareness and understanding, minimize negative thought patterns and behaviors, and develop new coping and problem-solving skills.

The four modules of dialectical behavior therapy:

In the case of adolescent treatment, Dr. Alec Miller has adapted Dr. Linehan’s model to incorporate parents attending skills training groups with their teens. There is an additional module, “walking the middle path,” which focuses on helping parents and their children understand each other’s viewpoints and reduce conflict and invalidation.

The five functions:

Dialectical behavioral therapy was designed to fulfill five primary functions:

Stages of treatment:

The course of DBT generally flows through three stages:

Who can benefit:

Though DBT originally was developed to treat more severe issues, such as borderline personality disorder, suicidal behaviors, and self-harm, the treatment has become a widely respected method for treating clients who exhibit the following, much milder traits and issues:

Dialectical behavior therapy has proven to be a very effective tool to help people manage intense emotions, change negative thought patterns, and decrease self-destructive behaviors. Individual therapy sessions focus on current detrimental behaviors in the client’s life, while group sessions involve learning skills from the four modules: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation.

GoodTherapy | Nicotine Withdrawal Induces Panic Response Individuals addicted to nicotine can exhibit unique responses when they are deprived of a cigarette. Many people report being anxious, snappy, or moody when they try to quit smoking. All of these responses are common. But for people with panic disorder (PD), going without a cigarette may trigger a panic attack. According to a recent study conducted by Teresa M. Leyro of the Department of Psychiatry at the University of California in San Francisco, people with anxiety problems and a history of panic attacks in particular are more likely to smoke than people without a history of anxiety-related problems. However, few studies have looked at how nicotine cessation, an event that can cause tension and stress in individuals with no history of anxiety, affects those with a predisposition to panic.

Leyro enlisted 58 adult smokers and exposed them to bodily sensations designed to elicit fear or anxiety. The participants were comprised of individuals with and without a history of PD, and all reported smoking approximately 20 cigarettes a day. The experiment was conducted after they had gone without smoking for 12 hours to allow sufficient time for withdrawal symptoms to occur. Leyro discovered that the participants with severe PD and the most significant withdrawal had the highest rates of panic symptoms after the experiment.

These results suggest that individuals with PD may catastrophize their circumstances and be more sensitive to physical cues when in a heightened state of anxiety. Additionally, these same individuals took longer to recover from their panic than those with low withdrawal symptoms. However, Leyro also found that the participants without PD and with low levels of withdrawal had elevated panic symptoms, too. This could be due to the fact that in the absence of withdrawal symptoms, these individuals may have been overly stimulated by fearful or threatening emotions when they experienced the physical sensations. Leyro hopes that these findings open up avenues of further research. She added, “This line of inquiry can shed light on the etiology of panic psychopathology among smokers and ultimately inform the development of novel specialized interventions for this difficult-to-treat population.”

Reference:
Leyro, T. M., Zvolensky, M. J. (2012). The interaction of nicotine withdrawal and panic disorder in the prediction of panic-relevant responding to a biological challenge. Psychology of Addictive Behaviors. Advance online publication. doi: 10.1037/a0029423

Related articles:
Three Steps for Dealing with Panic Attacks
Identifying and Treating Addiction and Substance Abuse Problems

People who drink coffee usually crave it first think in the morning. Similarly, individuals who enjoy a glass of wine or a cocktail after a long day of work may have physiological cravings during peak happy hour times. And according to a new study conducted by Lydia A. Shrier of Harvard Medical School’s Department of Pediatrics and the Division of Adolescent/Young Adult Medicine at Boston’s Children Hospital, young adults who crave marijuana also do so at specific times of the day. Persistent cravings are associated with high levels of relapse, regardless of the substance. People who crave sweets, alcohol, cocaine, or other substances tend to report that obsessions of cravings for their substance are what preceded their most recent relapse. Some reports suggest that the majority of individuals who receive treatment for drug addiction have cravings when they abstain. This is a primary symptom of withdrawal in drug and alcohol addiction and can lead to eventual relapse. To better understand what causes or increases cravings, Shrier gathered information from 41 young adult marijuana users over a period of 2 weeks.

The participants were cued six times a day, and they recorded where they were, who they were with, their level of desire to use, the availability of marijuana, and mood. Shrier discovered that even though the participants had all been selected because of their current drug use, just over half of them reported any desire or craving for marijuana during the study period. Of those who did, location, companionship, and time were critical triggers. For instance, the participants had more cravings when they were with friends than when they were with parents. Additionally, cravings were more common in the evening than in the morning. The participants in this study may have been engaging in more social activities in the evening and more academic or job-related activities in the morning. This would explain the increase in reported cravings during evening hours, a time that is often viewed as more social. Shrier said, “The association between times of day and increased desire suggests that intervention strategies recommending alternative activities be focused on vulnerable times.” She believes that marijuana use may decrease if individuals are able to reduce their desire for marijuana, especially in situations when cravings are strongest.

Reference:
Shrier, L. A., Walls, C. E., Kendall, A. D. , Blood, E. A. (2012). The context of desire to use marijuana: Momentary assessment of young people who frequently use marijuana. Psychology of Addictive Behaviors. Advance online publication. doi: 10.1037/a0029197

Related articles:
Identifying and Treating Addiction and Substance Abuse Problems
How to Control My Drinking: Techniques to Help You “Stop at the Buzz…”
Gambling—An Addiction for More Than Just Adults: One Teenager’s Story

GoodTherapy | Can Social Anxiety Be Caused by a Nutritional Deficiency?If you don’t get the right nutrients, your body won’t function to the best of its ability. Some general health conditions can be linked to nutritional deficiency, but it’s up for debate whether the same applies to specific mental health conditions. Some nutrition experts do claim that unique cases of social anxiety can actually be caused by a nutritional deficiency. In the condition several experts refer to as pyroluria, once the nutritional deficiency is taken care of, the social anxiety is relieved. Other experts are quick to dismiss the validity of this diagnosis.

Trudy Scott, a food-and-mood expert who said in an email that she has suffered from pyroluria, is a certified nutritionist, immediate past president of the National Association of Nutrition Professionals, and author of The Antianxiety Food Solution: How the Foods You Eat Can Help You Calm Your Anxious Mind, Improve Your Mood and End Cravings.

“The person experiences shyness, inner tension, and social anxiety,” Scott said in regard to symptoms of pyroluria. “Symptoms usually start in childhood and are made worse under stressful situations. The wonderful thing is that the symptoms can be completely alleviated with taking these supplements: zinc, vitamin B6, and evening primrose oil. People typically start to feel less anxious, less shy, and more social within a week. The important thing is that if you do have pyroluria, you do need to take the supplements always.”

Generally only zinc and Vitamin B6 are recommended for pyroluria, but “gamma-linolenic acid (GLA), found in evening primrose oil and borage oil, is also beneficial for those with pyroluria because its levels are often low, and supplementing with GLA improves zinc absorption,” she added. In her book about anxiety, mood, and food, she wrote a whole chapter about pyroluria.

“I am … very passionate about the subject because I have pyroluria myself and used to suffer terribly from social phobia and shyness, anxiety, unexplained fears, waking with a sense of doom and even panic attacks,” Scott said. “I have used the amazing healing powers of foods and nutrients to completely heal. I now help women find natural solutions for anxiety and other mood disorders.”

She has posted a questionnaire on her website for pyroluria. It includes a long list of symptoms, and if 15 or more items are checked on the list, it is likely a person has pyroluria: http://www.everywomanover29.com/blog/pyroluria-questionnaire-from-the-antianxiety-food-solution/

She said that in research studies, pyroluria is also called “the mauve factor.” “Much of what we know about pyroluria is based on the work of Humphrey Osmond, Abram Hoffer, and Carl Pfeiffer,” Scott said. “Much of the original work was done with schizophrenic patients in psychiatric hospital settings. Although pyroluria was first identified in the 1960s, the medical and mental health communities have been slow to recognize it, and many mental health practitioners and physicians remain unfamiliar with this condition.”

She said she learned about the condition mainly from reading the following books:
The Mood Cure by Julia Ross
Depression-Free Naturally by Joan Mathews-Larson
Nutrition and Mental Illness (1988) by Carl Pfeiffer

Her own book goes into the specific details and biological/chemical/genetic aspects of pyroluria. In her book, she cites research prevalence rates from Joan Mathews-Larson, the author of Depression-Free Naturally. Pyroluria is thought to exist in “11 percent of the healthy population” and “40 percent of adults with psychiatric disorders,” according to Scott’s book. For people with alcohol addiction, pyroluria is thought to have a 40% prevalence rate. However, the prevalence rates do depend on the source. In her own experience as a nutritionist, Scott said about 80% of her clients who have moderate to severe anxiety have symptoms associated with pyroluria.

She added that stress can be a major factor for what age pyroluria develops and that it is a genetic condition that seems to affect more women than men. In addition, people who have pyroluria tend to also have gluten sensitivity, especially if they also are dealing with other issues like depression, anxiety, autism, alcoholism, bipolar disorder, and schizophrenia, according to the book. People with pyroluria may also have digestive problems, and they need to make sure to balance out an increased Vitamin B intake with a higher intake of magnesium.

In the book The Mood Cure by Julia Ross, the author includes a discussion of the prevalence, testing, and treatment of pyroluria, as well as a checklist similar to that offered by Trudy Scott. Ross states that the questionnaire was developed by Dr. Carl Pfeiffer, a clinician and researcher. He wrote the book Nutrition and Mental Illness: An Orthomolecular Approach to Balancing Body Chemistry in 1988.

Ross states in her book that pyroluria is fairly uncommon in the general public, but in certain groups of people (like those who have experienced alcohol addiction), it is more common. “I am just getting familiar with this condition, but I can see that it is an important one for certain people, affecting stress levels and mood generally and preventing full response to nutrient therapy until it is addressed,” Ross wrote in her book.

There are a plethora of articles dedicated to nutrition, diet, and mental health in general, as well as multiple research studies suggesting that certain mental health issues can be improved through natural supplements and a healthy overall diet. “Notably, essential vitamins, minerals, and omega-3 fatty acids are often deficient in the general population in America and other developed countries and are exceptionally deficient in patients suffering from mental disorders,” according to an abstract from a research study in Nutrition Journal. “Studies have shown that daily supplements of vital nutrients often effectively reduce patients’ symptoms.”

Another abstract from a research article in the journal Alternative Therapies in Health and Medicine concludes the following: “Many patients will benefit from the use of specific dietary supplements, such as a multivitamin-mineral high in B vitamins and omega-3 fatty acid,” according to the abstract. “And no matter what the underlying cause of the mood disorder, patients should be counseled about the relationship between food and mood, for the evidence now substantiates what laypeople and medical professionals have long known intuitively: the way we eat affects the way we feel.”

The research, authored by Tieraona Low Dog, director of the fellowship at Arizona Center for Integrative Medicine at University of Arizona, added in the research abstract that the healthiest diet for improving mental health is a “low-glycemic, modified Mediterranean diet rich in fruits, vegetables, whole grains, and seafood (if not vegetarian) and low in processed, refined foods.”

Other experts remain unaware of the condition and are skeptical of its legitimacy. Scott Carroll, a psychiatrist with dual board certifications in adult and child and adolescent psychiatry, said in an email that he is not accustomed to pyroluria and had to look it up on Google to find out what it was.

“Once I saw that it is connected to orthomolecular psychiatry, which I have heard of, I knew it was in the pseudoscience realm,” said Carroll, who is also an assistant professor at the University of New Mexico School of Medicine. “Not surprisingly, it claims to be the cause of a number of unrelated psychiatric disorders, which is typical of pseudoscience disorders. Like so many ‘cure-alls,’ it sounds plausible, but there is no scientific basis to it, and it allows dubious practitioners to prey on desperate, suffering people.”

He said there are certain cases where nutrition can play a part in mood and mental disorders. “Inadequate amounts of Omega 3 fatty acids, especially from fish or krill oil, have been shown to affect mood and anxiety in a broad way of which social anxiety can be a part,” Carroll said. “Also, low folate, low Vitamin D, and low B12 have all been associated with negative effects on mood and anxiety.”

“However, in people with low folate, it is more often a case of a genetic inability to transport the folate molecule into the brain rather than a low blood level,” he added. “In those cases, which often present with chronic depression and anxiety that has never responded to antidepressants, there are folate precursors that are more lipophilic and can diffuse into the brain without use of a transport mechanism.”

Nerina Garcia-Arcement, a licensed clinical psychologist and clinical assistant professor at the NYU School of Medicine, said in an email that she didn’t study pyroluria in school and hasn’t read about it in any research studies after graduating from her doctorate program.

“Based on current knowledge it does not appear to be a legitimate health condition,” Garcia-Arcement said. “Further research is required to further explore and understand whether social anxiety or any other mental health condition could be related to improper synthesis in the blood.  Although this theory seems appealing, being able to ‘cure’ a mental disorder with vitamins or supplements … is unlikely.”

“Causes of social anxiety that have been substantiated by research include chemical imbalances in the brain (i.e., serotonin, a neurotransmitter), inherited traits (genetic and through observing anxious family members), negative life events or experiences, and an overactive amygdala (a part of the brain that controls emotions, including fear response),” she added.

She said that good nutrition is important for overall health, but it’s not necessarily linked to mental disorders. “In my experience, the social anxiety could be traced to other causes, not nutritional deficiencies,” Garcia-Arcement said. “Having a healthy and balanced diet is overall beneficial, but it won’t cure social anxiety or a mood disorder. I am more likely to recommend my clients get enough sun exposure to improve their moods (seasonal affective disorder) than recommend diet changes.”

Related articles:
Social Anxiety Can Be a Hidden Problem in College
Breathing Lessons
The Birth of Anxiety

two drinks at the barIn my practice as an addiction psychologist, it’s probably the most common question I encounter; when it comes right down to it, it’s what most people who are struggling with alcohol really want to know:

“How can I control my drinking or drug use?”

Only a small minority of people come to my practice with the expressed agenda of stopping their drinking altogether. Most seeking psychotherapy for alcohol dependence, misuse, or abuse have experienced some consequences due to their drinking and would like to minimize or stop those consequences but do not want to give up their drinking entirely.

For some drinkers, controlled drinking or moderate drinking is an option, and for a small portion of the population, about 5%, controlled drinking is nearly impossible. While many people believe “once an alcoholic, always an alcoholic,” many people diagnosed with alcoholism can learn to control their drinking and become social drinkers again. That said, if you have been diagnosed with alcohol dependence, most addiction psychologists, psychiatrists, physicians, social workers, and addiction counselors would strongly recommend abstinence. This is always a very personal decision that should be made with careful consideration of the risks and benefits of drinking versus abstinence.

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If one has never exhibited signs of alcoholism, then controlled drinking, a technique or approach that is a form of harm reduction, is a reasonable yet delicate first step. If one wants to pursue this approach, it is best not to go it alone. Talking to an addiction psychologist or other addiction professional can guide you through some generally recommended techniques.

Notice Feelings and Set Limits

Most addiction therapists will recommend two basic procedures that may differ in numerous ways but have the same central premise. The first is that you cut back your use of alcohol in whatever way you decide and that you then pay attention to what thoughts and feelings emerge. The idea here is that alcohol serves to mediate feelings by numbing, dulling, or blocking them entirely, and when you reduce your use or even stop drinking, your feelings will come back. As this happens, it is often recommended that you keep a journal or that you talk to your friends, family, partner, or therapist about these thoughts and feelings.

The well-known acronym “HALT” captures this eloquently. HALT stands for Hungry, Angry, Lonely, and Tired. These are the types of feelings people will experience as they reduce their alcohol or drug use. It reminds us to halt, or stop, and pay attention to what we need. Somehow, we have to cope with those feelings or risk relapse. If you are hungry, then eat. If you are angry, then tell someone, vent, exercise, pound a pillow, or express your anger in a healthy way. If you are lonely, then surround yourself with friends or start the process of finding new ones if all your friends drink. If you are tired, then sleep. Many people with alcoholism have an inability to take care of themselves, and learning this new skill in recovery is essential even with such basic behaviors as eating and sleeping.

A second basic tenet to alcohol counseling for people who are attempting moderate or control their drinking is to pick an amount of alcohol that they will not exceed and to stick with it. The National Institutes of Health recommend that, to maintain “low-risk drinking,” men consume no more than four drinks per day and no more than 14 per week. For women, the number is no more than three per day and seven per week. My personal belief is that this is fairly generous; a man can drink four beers while at a party on Friday or Saturday night, three or four during the football game on Sunday, three or four at bowling or poker night with the guys, and still have two or three with his partner on another day during the week.

When we can learn to stop at the “buzz,” we are well on our way to having our relationship with alcohol fully in check. For most people, three or four drinks make them feel tipsy or buzzed. Alcohol is a central nervous system depressant, yet the initial effects of alcohol in these amounts are more stimulating and euphoric feeling. People tend not to get into serious trouble from these amounts, but since the initial effects feel good, many people continue to drink past these amounts, assuming more alcohol equates to more good. It does not. It takes time for alcohol to work itself into your system, so people don’t realize how drunk they are getting, and in larger amounts alcohol has a depressing effect. The alcohol you drink today can make you feel depressed days and weeks later, and these small amounts can contribute to depressive feelings over time. Rarely has anyone come into my office with concerns about alcohol abuse because of drinking three or four drinks a few times a week.

Other Useful Techniques

To stick to the above drinking goals, there are other moderate drinking techniques that you can employ, such as avoiding hard alcohol and sticking to beer. Beer has lower ethanol content, and the carbonation can fill you up, so it tends to take longer to drink. Switching from alcohol to nonalcoholic drinks and back can slow you down as well. Holding a drink with lime or lemon may deter others from thinking you are not drinking an alcoholic mixed drink, and they may be less likely to offer you another drink. Remember, you are more aware that you are not drinking your normal amount or that you have reduced your consumption, and others probably aren’t even aware that you made any changes.

One technique to help you be honest with yourself is to take four coins (or as many coins as you are planning to have drinks that night) and place them in your back pocket. Each time you take a drink, move one of the coins into your other pocket. This may be more important if you are planning on drinking larger amounts of alcohol, and many of the people I work with start out reducing their drinks per setting with numbers more like from 10 to five or six, for example, so counting drinks becomes more important. This way, when your coins run out, you can be sure not to exceed the previously determined limit that you imposed on yourself.

Many addiction therapists recommend one drink per hour as another way of limiting oneself. Since alcohol leaves the bloodstream at about .02 blood alcohol content (BAC) per hour, this will most likely keep your BAC at a reasonably safe level. In using this technique, it is recommended that you discuss your upper limit with a certified addiction professional or addiction psychologist.

It goes without saying that it’s important to pay attention to drink equivalents. A typical shot equals one 5-ounce glass of wine, which equals one 12-ounce standard beer. If your favorite bartender is pouring your drinks and he knows you are a big tipper who likes to drink, you might need to have a brief conversation with him. Believe me, bartenders are used to these conversations, and they will not hold it against you. In fact, most bartenders will be very respectful and discreet and will keep an eye out for you thereafter. If your buddies are trying to get you drunk, that’s another story. Watch how much they pour. A Long Island Iced Tea counts for three drinks, not one.

Don’t Try to Drink Away Emotional Pain

While I consider myself to be an open-minded therapist, what would an alcohol blog be without a major caution? Here’s my warning: Don’t drink when you are sad, anxious, lonely, worried, or in any negative feeling state. These are times when you should figure out healthy ways of coping. If you drink during these times, you are at high risk for using your drinking as a crutch.

What happens if you can’t control your alcohol use with these techniques? After trying these techniques and determining your level of success, you should be able to assess whether you can be a social drinker. To the extent that you break any of the rules that you set up as an experiment and exceed these drinking limits with resulting consequences, then it is time to reconsider lowering your upper drinking limits and decreasing the frequency, quantity, intensity (alcohol content), or duration of your alcohol use.

If you are wondering whether you have a drinking problem, please read Do I Really Have a Drinking Problem?

An addiction psychologist or other psychotherapist specializing in addiction can help you answer any questions or develop a plan that, over time, will enable you to understand the role that alcohol plays in your life and make decisions about what, if any, changes you are ready to make. You don’t need to figure this out on your own. It takes courage to seek help for alcohol use. If you are reading this, you are well on your way to understanding yourself better and getting what you want and need in life.

Young man walkingPeople in their 20s seem to have it all: youth, energy, health, and looks. But they are also still figuring themselves out, and this time of change can bring certain mental health concerns as well. Experts have information on these issues that tend to impact people in their 20s, and provide some solutions for addressing and coping with these problems.

Clinical psychologist Dean Haddock, a marriage, family, and child counselor and the executive director and founder of Community Counseling and Psychological Services, points to a fairly common activity of 20-somethings that can lead to mental health issues if it’s not checked: alcohol and drug use.

“The first problem that leads to many others is alcohol and chemical abuse, which often leads to dependency,” Haddock said in an email. “The mental disorders that follow are often depression, anxiety, and brain injury. Of course, self-esteem and body-image problems often lead to eating disorders.”

Haddock gives three tips to help people in their 20s prevent and get through some common mental health concerns:

  1. Know your genetic history of mental disorders. Knowing is half the battle to avoid those disorders in yourself.
  2. Be choosey about your friends, as they will influence your decisions. Healthy friends lead to healthier decisions.
  3. Self-esteem is often the result of the people who matter to you. If they do not esteem you, then you will not esteem yourself.

Nerina Garcia-Arcement, a clinical psychologist and clinical assistant professor at NYU School of Medicine, suggests that the many life changes people experience in their 20s can cause mental health issues at times.

“Your 20s are filled with life transitions that can be stressful,” Garcia-Arcement said. “This is a time when young adults are solidifying their personalities, developing their independence from family, starting or finishing college, beginning new jobs, developing a career, forming romantic relationships, and learning to manage their existing family relationships and friendships within these context.”

“Individuals in their 20s don’t have a lifetime of experience to draw on when managing multiple life transitions at once,” she added. “When someone experiences these transitions, anxiety and depressive disorders can occur.”

Here are six of Garcia-Arcement’s tips to help people in their 20s cope with mental health issues more common to that age group:

  1. Seek out and form strong support networks.
  2. Seek out others who are going through similar experiences and share your feelings, whether you are feeling worried, nervous, scared, sad, confused, or excited.
  3. Know that you are not alone in your confusion about your career and relationships.
  4. Seek out mentors who have achieved their goals, and ask for advice.
  5. If you are feeling stress, sadness, or anxiety, engage in activities that will help you manage those feelings such as yoga, meditation, exercise, hobbies, social activities, relaxation exercises, and deep breathing.
  6. If you feel you are not getting the necessary support and feel overwhelmed or depressed, seek out mental health professionals who can help you manage the feelings related to your life transitions.

Stephanie Sarkis, a licensed mental health counselor, said in an email that anxiety and depression are some of the main mental health issues 20-somethings face.

“We have seen an increase in these issues due to the lagging economy and difficulties finding employment,” Sarkis said. “Many people in their 20s have moved back in with their parents, which can trigger feelings of failure and frustration.”

Dr. Maiysha Clairborne, a family physician and wellness and stress management coach, added in an email that eating disorders associated with body dysmorphic disorder and body-image issues are also common for people in their 20s. She has three overall tips for people in this age group:

  1. Talk to someone. The worst thing that a person can do when they are feeling depressed, anxious, or alone is to isolate more. Many times when we talk with someone we trust about what’s going on, we come to realize that we are not the only ones experiencing it and then we can get support.
  2. Get active. Staying physically active not only helps to keep the body fit but also helps release endorphins and serotonin in the brain, which help keep the mood elevated. Physical activity is also a good release for stress and anxiety.
  3. Minimize sugar and junk food. Sugar and processed junk foods can worsen the emotions of stress, anxiety, and depression because they cause erratic changes in your body’s blood sugars. This can disrupt the normal release of hormones in the brain that keep your moods stable.

Scott Carroll, a psychiatrist with dual board certifications in adult and child and adolescent psychiatry, said there are many issues specific to people in their 20s, including problems associated with medication use.

“Many people were on stimulants/meds for their ADHD when they were younger, but they thought it was okay to stop their meds when they were done with school,” Carroll said. “Now they are struggling at work and don’t know why. I’ve also seen young adults stop all kinds of meds like their thyroid meds because they didn’t know why they were even on it, and then they have all kinds of problems.”

Bad habits involving drug and alcohol use can start to become a major substance abuse issue when people are in their 20s, and other mental health issues start coming to the forefront at this time in peoples’ lives. Examples include bipolar disorder and schizophrenia. Also, panic attacks can start for people who have a genetic predisposition and who have higher amounts of stress associated with newfound adulthood.

“The 20s are an important time of social/emotional development,” Carroll said. “Unlike previous generations, identity formation often takes the entire 20s due to the complexity of modern society. It could be said that adolescence lasts until the early 30s in today’s society due to [prolonged] periods of education (grad school, law school, med school, etc.), lack of stable job options, and delays in getting married and starting families.”

Carroll, who is also an assistant professor at the University of New Mexico School of Medicine, suggests that when it comes to serious relationships and marriage, people in their 20s should consider how their choices could eventually affect their mental health and how their brain plays a part in their decision.

“Many 20-somethings are tempted to get married, but it is generally a bad idea because the brain in not done developing until about 25 [years old] … which leaves young adults vulnerable to having their rational mind be overwhelmed by their feelings or stress,” Carroll said. “Relationship choices often dramatically change from the early 20s to the late 20s, so many people find that the person that was perfect at 22 is a disaster at 27.  This can be an incredibly hard transition, to have to break up with your former soul mate that you thought you’d love for life because you’ve changed so much over the last several years.”

Related articles:
Do I Have a Healthy Relationship With Food and My Body?
Social Anxiety Can Be a Hidden Problem in College
How Schools Could Prevent Depression

As an illegal psychostimulant drug, cocaine has ravaging effects both on the individual user and on society as a whole. The addictive qualities of cocaine are well-documented, and users often persist in their abuse despite one negative consequence after another. The search for effective, reliable treatments for cocaine addiction is ongoing. Recently, the antipsychotic drug Abilify (aripiprazole) has shown some potential as a treatment both for those currently addicted to the drug and those in the recovery stages. A pair of experiments with mice demonstrated that Abilify blocks some of the positive, rewarding effects of stimulant drugs while also reducing the odds of relapse.

In the earlier mouse study, Abilify reduced “self-administration” of cocaine in mice. As the dosage of Abilify was increased, the effect was more pronounced. At the same time, the mice did not seem to “overcome” the effects of Abilify by administering higher doses of cocaine. Researchers believe that part of this medication’s action on the cellular level actually negates the action of cocaine and possibly other stimulants. Another positive aspect of Abilify is that it seems to lack any obvious rewarding qualities of its own. The mice did not self-administer more Abilify in lieu of cocaine, an important quality that enhances its potential as a treatment for drug-addicted humans.

A later study examined whether Abilify could reduce relapse of cocaine addiction. In this experiment, mice were presented with the opportunity to self-administer cocaine after a 2-week period of withdrawal from the drug. Mice that had been given scheduled doses of Abilify showed far less potential for relapse. Apparently, the medication establishes a kind of “blockade” around the receptor sites to which cocaine typically attaches. This revelation is important for those who work directly with individuals in the field of drug addiction.

Addiction to cocaine and other stimulants continues to be a public health epidemic. Researchers are on a quest to discover effective pharmaceutical treatments for addiction. Because of repeated successful trials, low incidence of side effects, and generally high tolerability, Abilify has been identified as a potentially very useful tool in the battle against psychostimulant addiction. Abilify both reduces the immediate reward effects of cocaine and reduces the odds of relapse during the recovery phase. As a supplement to group counseling or talk therapy, treatment with Abilify may give recovering addicts a powerful advantage in their struggle to restore normalcy in their lives.

 References

Close up of thoughtful womanIf you are reading this article, then you probably have completed Codependency Workbook Exercise Two by creating a list of your troubled relationships. Congratulations for completing this. Generally, in codependent relationships there is some pain and emotional abuse. They tend to be rather lopsided, with you doing most if not all of the giving. When you realize this, you may get angry and feel as though others are using you. You may wonder why this is. It is because when they meet you, they sense that you are a caretaker who will want to help them. When you do this, it is because you care about them and believe that you can love and care some of their problems away. Most of the time this cannot be done. Often, by giving to them, you are actually making it easier for them to continue their maladaptive behavior.

If your loved one gets a DWI, you may rush out and hire a good lawyer who may get him or her off. Had this person suffered the consequences of the DWI, he or she might have been ordered to complete substance abuse treatment, which might have ended or at least interfered with the drinking. So if you are in a relationship with a person with an alcohol or drug problem, can you think of a boundary that you could set that would be good for you and, in the long run, him or her? For example, you might tell this person that if he or she has another legal problem related to substances, that you will no longer help. The person will be on his own. Of course, he or she may not like this and try to push your guilt buttons. Remind yourself that you are not only doing what is best for yourself but also for the other person. You might take your boundary a step further and tell the person that effective immediately, you will no longer undo any of the consequences of his or her using. I suggest you only set the boundary when you are ready. The hard part will come when you have to stick to the boundary. You will need some support from a therapist, your sponsor, or a friend to hold to it. Once you maintain a boundary you will find that it is easier to stick to the next one.

What are some other boundaries that you might set? Maybe you have a friend who borrows money from you and has never paid it back. The next time the friend asks to borrow money, you might tell him or her that you are unwilling to loan any more money until the person repays you the funds already owed. Maybe you have someone who always asks you for rides but never offers to pay for your gasoline. You might decide to tell this person that you cannot afford to continue giving him or her rides. Make a list of all the boundaries that you need to set to take care of yourself. While you are identifying them, do not worry about actually setting them. Try to take one step at a time. I know that the thought of setting them is very scary. You may also be scared about what will happen to your friend if you set them. If your friend is dysfunctional, something will happen to this person no matter what you do. Once you get the hang of doing this, you are going to feel an enormous sense of relief. You will realize you are not responsible for everybody, nor do you have to help someone just because that person needs it.

If you are like some people, you may fear that if you stand up for yourself, you will be abandoned by your friend. I believe that if this happens, then that person was not really a friend to begin with. Can you imagine treating someone that you care about like that? I am sure that you cannot. Now you will have more energy to direct toward taking care of yourself. You will no longer feel so angry at others. The next time you feel like a victim, you may need to check and see if you need to set another boundary.

Several research studies have investigated the possibility that the antidepressant medication Luvox (fluvoxamine) could be an effective therapy for alcoholism. Most of the studies involved rats, but researchers consider the results applicable to humans as well. Despite the enormous public health burden of alcoholism, treatments for the disease are still well behind the curve. The rate of successful remission and abstinence is low, regardless of treatment plan. Comorbid disorders such as severe depression or anxiety further complicate matters and increase the likelihood of eventual relapse. Adequate treatment usually requires a combination of approaches—cognitive therapy for treatment of mood disorders, pharmaceuticals for managing alcohol withdrawal and cravings, and ongoing counseling to reduce the chances of a return to drinking.

A study with lab rats revealed that Luvox potentially reduces the response to food, or alcohol, or both, depending upon the experimental conditions. The goal of the study was to determine if Luvox might reduce the craving for alcohol, but the results were not conclusive in that regard. Significant changes in stimulus response were recorded even at very low doses of the medication. When food and alcohol were presented together, rats treated with Luvox responded less to food but maintained the same consumption of alcohol. However, presenting one stimulus and then another in sequence had differential effects. Responses to the second stimulus, regardless of whether it was food or alcohol, were decreased in the presence of Luvox. The temptation has always been to link all reward-seeking behaviors into a single category. Studies like the above, however, demonstrate that food-seeking and drug- or alcohol-seeking are biologically distinct events. The intricate and complex workings of such behaviors are still largely mysterious.

Due to uncertainties in its effectiveness for the purpose, Luvox is unlikely to play a role in the reduction of alcohol cravings. The rat studies returned mixed or confusing results, and no human trials have demonstrated a predictable, reliable mechanism of action. At this time,  there  isn’t enough evidence to conclude that the medication can successfully manage alcohol cravings. However, Luvox is effective in treating the depression and anxiety that accompany the recovery process after alcoholism. As a safe and effective mood stabilizer, Luvox reduces the chances of relapse. When Luvox is combined with cognitive therapy, a person recovering from alcohol addiction has a high likelihood of achieving a healthy outcome.

References

  1. PubMed Health [Internet]. (n.d.). Bethesda (MD): National Library of Medicine. Fluvoxamine. Retrieved April 4, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000955/
  2. Ginsburg, B. C., Lamb, R. J. (2006). Fluvoxamine effects on concurrent ethanol- and food-maintained behaviors. Experimental and Clinical Psychopharmacology, 14(4), 483-492.

Probation officers assume a large level of responsibility for the offenders in their care and the community at large. They are responsible for monitoring criminal offenders and assessing what level of risk they pose to the general public. When offenders commit an infraction, such as a technical violation of not meeting the conditions of their probation, it is up to the probation officer to manage that infraction and ultimately decide the consequence. Individuals who struggle with mental health issues such as depression, schizophrenia, and bipolar account for a large percentage of offenders. Unlike offenders with substance abuse problems, the main cause of reincarceration for mentally ill offenders is a technical violation, not a new criminal offense. Research has shown that in fact, mentally ill offenders are just as unlikely to commit a new offense as are offenders with no history of mental illness or drug abuse. But unfortunately, mentally ill offenders are monitored more closely and assessed more harshly than substance abusing offenders.

Jennifer Eno Louden of the Department of Psychology at the University of Texas recently conducted a study to better evaluate the conditions by which probation officers assess and manage mentally ill offenders. Her goal was to determine whether these offenders were being unfairly assessed, resulting in increased rates of reincarceration. Louden enlisted 234 probation officers and presented them with probation violation scenarios committed by a mentally ill offender, an offender with substance use issues, an offender with both problems, and an offender with neither. She evaluated their risk assessments and management recommendations and found that even though statistics show substance users as more likely to engage in violent acts, the officers rated the mentally ill offenders as being 13% more likely to commit acts of violence.

The primary risk management strategy recommended by the officers was forced psychological treatment, usually in the form of medication. Although mental health treatment is not a negative recommendation, forcing the treatment is seen as a cause for concern. For these individuals, many of whom have schizophrenia, the negative side effects of medication can cause more harm than good. The goal of treatment was not helping the offenders address their mental health problems but rather managing their behavior; however, it did not help them decrease their chance of reoffending. Louden believes this study demonstrates the need for further training and education for probation officers who work with mentally ill offenders. She said, “By targeting interventions away from a sole focus on mental disorder toward robust predictors of recidivism, real improvements can be made in the criminal justice outcomes for offenders with mental disorders.”

Reference:
Eno Louden, J., Skeem, J. L. (2012). How do probation officers assess and manage recidivism and violence risk for probationers with mental disorder? An experimental investigation. Law and Human Behavior. Advance online publication. doi: 10.1037/h0093991

Close up of white roseThe following is an open letter to my sister Andrea Haber, who died from complications due to alcoholism on 10/31/11.

Dearest Anj:

Just a note to let you know how much I miss you. It’s still so bitterly ironic to me that what killed you is the very disease I’ve devoted my life to battling. But in a way, your alcoholism never gave you a chance.

I’m sorry we never talked about it, although you can’t say I didn’t try. There was a time, a few years back, when you told me you wanted to talk about it, and my heart leapt. But that talk, like so many hoped-for moments, never materialized.

I believe when I first got sober I wrote you a somewhat long-winded, pompous letter about the perils of drinking. I’m sorry again that I preached at you like that. You handled it with grace but I cringe now at the thought of my presumptuous rambling. Newly sober people often think they can save the world with a few well-chosen phrases. I guess I thought there was really something I could do. Naïve, yes, but even at the end, and maybe even now, I often feel the same way.

I miss your letters. They really made me laugh. You were a fabulous writer and I think that you, as with so much else, underestimated yourself. Their absence has created a very loud silence.

I’m sure you’re thinking, “Gee bro, nice cheery letter!” I only wish I could be more cheery. This is an occasion I never wanted— that even with the grim medical news coming from Pittsburgh, I never really saw coming. There’s just no good way to spin the loss of someone so young, so beautiful, so amazing. Part of the tragedy for me is, I don’t think you ever truly understood just how loved you were. Mom told me you were shocked when she said to you, near the end, how much you’d be missed should the worst happen. This too, is another symptom of addiction: the disbelief that we matter to people, the certainty that we’re really “only hurting ourselves.”

Hard to be cheery when feeling so cheated…

Of course, denial is the hallmark of this loathsome affliction. We grew up with rationalizations and minimizations aplenty when it came to Dad’s drinking and the family’s Nixonian “cover up”—i.e., “Don’t talk about it, too embarrassing” (Dad’s favorite) and “It’s not that bad” and “Don’t exaggerate,” all repeated like mantras. Even I, near the end, felt that chances were good you’d come around; see the light, get sober. Your disease made a mockery of my optimism.

So hard to sit on the sidelines and simply try to accept. I’ve struggled lately with, “Did I really do enough?” Should I have gone all out and planned an intervention, John Wayne style? Should I have demanded you listen to me until “the truth” sank in? I already felt like a stick in the mud, the voice of gloom, whenever you called or wrote me and wanted to laugh or kid around; I loved the jokes but was so terribly worried about your well-being. We had a trove of inside jokes, a bulwark against the despair of growing up in that chaos and emotional violence. I cherished the humor but wondered what might be going on underneath. There is a pain we can’t hide from, I have found, no matter how clever or humorous we are. When your doctor handed you that grim prognosis last year, that you either stop drinking or die, I thought “well this is it, she can’t ignore it any longer.” Wrong again, bro!

Of course the cliché is that there’s nothing you can do to get a person to stop; no amount of begging or pleading or coercion will ever do the trick. Maybe briefly, superficially, but it’s an “inside job” (as they say) when it comes to lasting change. We can give someone just about anything, except motivation to do the hard but necessary thing. I kept thinking you’d finally “hit bottom” when the doctors told you your liver was shot…until mom told me this wasn’t the case, that she feared nothing was changing. I backed off a bit because I know how she hounded you. Maybe that was a mistake. Maybe hearing it from me would’ve got you moving.

I cringe when I see the pride and ego in that last sentence. Yes, you should have heard it from ME, your big brother, sober white knight on the West Coast, brandishing a master’s degree in psych., saving souls and fighting the good fight. I wonder if you’re chuckling as you read this.

Perhaps it’s pretentious of me to think I had the slightest idea of what might be good for you. I had no idea what was really going on in your life, and I suppose it was none of my business. Maybe the long, hard climb back to sobriety might have been too difficult; perhaps too many skeletons, whatever they were, had accumulated in the closet for any one person to face.

But saying “There’s nothing I could have done” doesn’t seem to help. Maybe that’s why I’m writing you now; perhaps, in my Jewish neurotic guilt, I struggle towards some kind of absolution. Doubt has always dogged me; so hard to not look over my shoulder in almost every instance. This is no exception. Could I have somehow said more, done more, pushed harder to help you “see the light”? (Am I hearing that chuckle again?)

Just this morning I advised the mother of a patient that there was nothing she could do to “get” her daughter to stop using and go to meetings. I thought, “Wow she really thinks there’s something she can do!” So easy to sit in one’s cozy office chair and dispense wisdom to the struggling, misguided souls asking for help…

Here’s the hard part (as if there’s an easy part!): You can detach, stop trying, accept another’s addiction, respect their “life choices” and move on. But how to really “move on” when it’s your own flesh and blood? You can stop obsessing, stop letting the person’s disease hold your serenity hostage, attend Al-Anon meetings, seek counseling…but the kind of Zen-transcendent it’s-all-good acceptance I’ve perhaps subtly advocated to others isn’t possible, at least not for me, at this point in time.

Because I can’t stop loving you. Can’t switch off the caring. How could it be otherwise?

Maybe the idea is to make room for both, the love and the acceptance. It’s not either-or (as I’m fond of telling my patients). You can love the person and hate the disease. It’s just hard to stand by and watch a loved one fall to pieces and to try and pretend it’s not happening. It’s like a fatal car accident happening in slow motion right outside your door. I prayed every night for you to find the desire to stop drinking. I struggle to accept it never happened.

I know you meant no harm, Sis, and I never took it personally. I think if you could have stopped, you would have; as I say, the odds were seriously stacked against us from the get-go. I don’t know why I hit the lucky number; I just know it’s a gift that I protect with my life, and I would have given anything to have shared it with you. I tried.

I hope you know that somehow, wherever you are, I was worried but not condemning you. There is so much shame with this thing but I always longed to say to you, How could you not be an alcoholic, with all the crap we had to deal with? Even so, I underestimated the awesome power of this thing, and can only guess at how you suffered beneath the chuckles, the jokes and that wonderful wit of yours. It’s just hard to accept that, in this case at least, love was not enough…so difficult at those times when I think of our private jokes and laugh and want to email you…hard to really accept that my kid sister—my first friend, my loyal ally—is really, undeniably gone…

 Related articles:
The Pendulum of Grieving
Over-Extended: Thoughts on Boundaries in Addictive Families
In Case of Emergency: Seeking Help When a Loved one Struggles with Addiction

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